Gastrostomy Tube Insertion Guideline

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The Insides® System Training Manual - Gastrostomy Tube Insertion

This document is to be used in conjunction with IFU-1 The Insides® System Instructions and Technical Description, and IFU-2 The Insides® System Setup Guide for Healthcare Professionals

  1. Ask the patient to lie down in a comfortable position. Have the patient remove the ostomy appliance and clean the area.
  2. While they are cleaning the stoma, put on gloves and prepare a clean work area next to the patient.
  3. It is recommend to use a gastrostomy tube that is at least 20 Fr in size.
  4. Remove the gastrostomy tube (tube) from the packaging and lubricate the tip and up to the first 10 cm of the tube.
  5. Instill 10 ml of “water for injection” into the balloon to ensure it inflates symmetrically and then remove the water from the balloon. Save the water filled syringe so it can be utilised later.
  6. If the tube has a flange, manipulate it further down the tube, so it is away from the tip. Lubricant may be used to assist with this.
  7. Insert a gloved and lubricated finger into the distal limb of the stoma or fistula. Digital palpation allows the direction of the limb to be assessed and provides a sense of the state of the fascia (tight or narrowed).
    1. Feel the fascia to determine how far to insert the tube. An extra 3 cm of the tube is needed to ensure the balloon reaches beyond the fascia.
  8. If the distal limb feels tight or kinked, insert another 10 ml of lubricant down the limb of the stoma.
  9. The patient may feel some abdominal discomfort or unusual feeling but it should not be painful. Assure the patient that this feeling is normal and is due to the stretching of the lumen in the bowel. If it is painful, this needs to be investigated further.
  10. Change gloves before proceeding to the following steps to achieve better grip as there may now be an excess of lubricant.
  11. Rest a non-dominant hand around the distal outlet, to guide the tube that is being pressed in with the dominant hand.
  12. Ask the patient to describe any pain felt upon insertion. Some mild discomfort is expected due to the stretching of the lumen of the bowel.
  13. Slowly press the tube in with a dominant hand. Press the tube in until it arrives at the predetermined length.
  14. The bowel may not allow the tube to press straight in. Allow the bowel to take the tube with peristaltic movement.
    1. Do not force the tube in. Instead, apply light pressure to ensure the tube keeps moving; this may take up to 1 minute.
  15. Once satisfied that the balloon is beyond the fascia, hold the tube with a non-dominant hand, connect the syringe to the balloon connector and instill 3-4 ml of “water for injection”. Inflate the balloon to 3 ml to reduce the risk of pressure necrosis and reduce the pressure exerted on the lumen allowing the chyme to flow from the tube into the distal limb.
  16. Give the tube a gentle tug to make sure it is in place under the fascia.
  17. If the gentle tug dislodges the tube, pull it fully out, remove the “water for injection” from the balloon and reinsert again. Instill 4 ml of “water for injection” into the balloon this time.
  18. If there is a flange on the tube, move this into position, approximately 1-2 ml from the stoma outlet.
  19. Place The Insides® Pump (Pump) on the end of the gastrostomy tube and measure against the bag. A high output ostomy appliance will be required to fit the tube and Pump comfortably. It is recommended to use a clear ostomy appliance so the tube can be visualised.
    1. The Pump cannot be pressed against the end of the bag.
  20. Allow the patient to practise removing the Pump and replacing it without disturbing the tube. Make sure that the Pump is threaded appropriately up to the second or third thread.
  21. Prepare the stoma and skin so that the ostomy appliance can be attached. Let the patient practise this so that they are correctly applying everything and not disturbing the tube.
  22. If required, thread the seal over the Pump and the tube and secure in place to protect the peristomal skin. Ask the patient to thread the ostomy appliance over and secure in place.
  23. Once the ostomy appliance is secured in place, ask the patient to sit up to ensure that the tube and bag sit flat with a low profile against their abdomen.
  24. Ensure that the Pump is not pressed against the bottom of the bag. The Pump, when attached, should sit 10-20 mm above the bottom of the ostomy appliance.
  25. The patient should feel comfortable (or have very mild discomfort that can be resolved with Paracetamol/Acetaminophen).

Troubleshooting Insertion

  1. When inserting a little finger to dilate and assess the lumen, if it feels tight or if a kink is detected, try inserting a thinner diameter Foley catheter.
    1. Try inserting a 10-12 Fr Foley catheter to “straighten” the distal limb.
      1. The clinician should decide whether to leave the Foley in situ and run the tube alongside the Foley as a guide or whether to remove the Foley and insert the tube.
  2. Use ample lubricant when placing tube. If possible, place the lubricant in a syringe and syringe it downstream.
  3. Peristalsis can dictate how quickly the tube will be accepted into the distal limb. Peristalsis will also dictate how the tube sits once left in place. Peristalsis may press it out or draw it in. If it is comfortable for the patient and it does not fall out, it is okay for there to be some movement. A flange (if still in situ) and the Pump will stop the tube from being pulled downstream.
  4. The Pump is 35 mm in diameter, if the patient’s template size on the ostomy appliance is smaller than this, there are three options:
    1. Make a small incision at “3 and 9 o’clock” on the template of the ostomy appliance so that the Pump can be pushed through more efficiently.
    2. Take the Pump on and off via the opening at the bottom of the ostomy appliance.
    3. Cut a larger template of the ostomy appliance and use an ostomy seal to protect the exposed skin.

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